Provider Demographics
NPI:1689867889
Name:FEHNIGER, MATTHEW D (PT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:D
Last Name:FEHNIGER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40767
Mailing Address - Street 2:CREDENTIALING DEPARTMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32203-0767
Mailing Address - Country:US
Mailing Address - Phone:904-376-3707
Mailing Address - Fax:904-391-5807
Practice Address - Street 1:1577 ROBERTS DR STE 320
Practice Address - Street 2:CREDENTIALING DEPARTMENT
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3266
Practice Address - Country:US
Practice Address - Phone:904-247-3324
Practice Address - Fax:904-247-3926
Is Sole Proprietor?:No
Enumeration Date:2007-08-21
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT23513225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00420320OtherRR MEDICARE
FLAF342ZMedicare PIN